Public Health Committee

JOINT FAVORABLE REPORT

Bill No.:

SB-36

Title:

AN ACT CONCERNING THE GOVERNOR'S RECOMMENDATIONS TO IMPROVE ACCESS TO HEALTH CARE.

Vote Date:

3/10/2014

Vote Action:

Joint Favorable Substitute

PH Date:

2/28/2014

File No.:

SPONSORS OF BILL:

Public Health Committee

REASONS FOR BILL:

To implement the Governor's recommendations concerning advanced nursing practice.

Substitute Language: This bill would allow advanced practice registered nurses (APRNs) who have been licensed for at least three years to practice independently without written collaboration with physicians.

RESPONSE FROM ADMINISTRATION/AGENCY:

Jewel Mullen , MD, MPH, MPA: Commissioner, Department of Public Health (DPH):

The Department of Public Health supports the bill.

Section 1 upholds the requirement that an Advanced Practice Registered Nurse collaborative agreement with a physician for the first three years after having been issued a license. Thereafter, the APRN would be authorized to practice without a written agreement. The APRN can practice alone or in collaboration with a physician or other health care provider and may perform acts of diagnosis and treatment of alterations in health statutes, prescribe, dispense and administer medical therapeutics, corrective measures and drugs (including the form of professional samples).

Section 2 amends the portion of the medical practice act that references APRNs to remove the language that currently requires APRNs to have a collaborative agreement. The language properly references the new requirement that collaboration is required for the first 3 years of practice.

The Health Resources and Services Administration of the United States Department of Health and Human Services projects a shortage of 20,400 primary care physicians nationwide by 2020. Other organizations set that projection much higher. Analyses conducted by the DPH Office of Health Care Access reveal that although the availability of primary care providers in our state is somewhat better than the national average, geographic distribution of and access to primary care providers is uneven. Access is particularly challenging for uninsured and underinsured individuals. Implementation of the Affordable Care Act will increase the demand for services among newly insured. Our commitment to ensuring they receive care is the basis for the Governor's proposal.

I want to reiterate that this proposal does not turn nurse practitioners into physicians. Moreover it is not intended to diminish the medical profession, nor does it reflect an inflated perspective on the capabilities of nurse practitioners. The Governor's proposal to allow APRN independent practice aligns with similar recommendations of esteemed organizations such as the Institute of Medicine, the National Governor's Association, and the Robert Wood Johnson Foundation, all of whom view APRN independence as a means of improving access to primary care.

The DPH scope of practice review process was established by PA 11-209 An Act Concerning the Department of Public Health's Oversight Responsibilities Relating to Scope of Practice Determinations for Health Care Professionals. DPH had sought this legislation 3 years ago to formalize a process for submission and review of scope of practice requests. The provisions established guidelines for all petitioners to follow, and require a committee vetting process which is transparent, objective and inclusive.

In accordance with the PA 11-209, DPH submits a formal scope report to the Public Health Committee, but we do not approve or deny a request. That is the role of the legislature. The details of the APRN scope process are summarized in the Scope of Practice Review Committee Report on Advanced Practice Registered Nurses which was submitted to the Public Health Committee on February 1, 2014. I will include a short list of salient points from the report:

1. Practicing APRNs increase access to care, particularly in underserved areas.

2. Research supports that there is a range of conditions and functions that APRNs can and do perform without evidence that patient safety suffers.

3. Within that range of conditions and functions, NP's produce outcomes that mirror those produced by MD's

4. Many of those conditions and functions are at the core of APRN practice: evaluation, screening history taking, and physical examination; and management of a number of routine medical conditions such as hypertension, diabetes, asthma, and patient functional status.

5. APRN patient satisfaction scores are comparable to or higher than those of physicians, in part due to the time they can spend with their patients and their emphasis on holistic care.

6. Hospitalization rates are similar among patients treated by APRNs and those treated by physicians. Mortality rates also are similar.

7. The DPH scope review process did not uncover evidence that the care APRNs provide is unsafe, and not such evidence was presented to the committee.

8. Residency training programs for APRN graduates will strengthen their preparation for independent practice.

The Department respectfully requests the following language be added as a technical amendment:

Sec. 3 Subsection 20-94b of the general statutes is repealed and the following is substituted in lieu thereof:

An advanced practice registered nurse licensed pursuant to section 20-94a and maintaining current certification from the American Association of Nurse Anesthetists may prescribe, dispense and administer drugs, including controlled substances in schedule II, III, Iv, or V. An advanced practice registered nurse licensed pursuant to section 20-94a who does not maintain current certification from the American Association of Nurse Anesthetists may prescribe, dispense, and administer drugs, including controlled substances in schedule [IV] I, III, IV or V [except that such an advanced practice registered nurse may also prescribe controlled substances in schedule II or III that are expressly specified in written collaborative agreements pursuant to subsection (b) of] in accordance with section 20-87a as amended by section 1.

Victoria Veltri, JD, State Healthcare Advocate, Office of the Healthcare Advocate:

Supports the bill. With more than 125,000 new entrants into Connecticut's insurance marketplace and a greater understanding of the critical importance of early access to preventative screening and care, developing workforce capacity remains an important element in effective health reforms efforts. SB 36 Begins to address this issue by capitalizing on our state's existing clinical expertise and enabling Advanced Practice Registered Nurses (APRNs) to diagnose and treat to the full extent of their training and with full independence.

This expansion enhances medical's doctor's ability to focus on more complex patients, while maximizing access to effective, quality and compassionate primary care for consumers with more routine healthcare needs. Also, the bill can help reduce healthcare expenditures by leveraging the expertise consistent with each provider's training and experience, create more equity in the quality of healthcare delivery.

Roberta Willis, State Representative: I believe that a good clinician needs extensive clinical experience and a rigorous academic background and I believe APRNs have both. APRNs have graduate-level degrees, hundreds of clinical hours of supervised practice, and must pass national certification exams.

While APRNs do not complete a post-graduate residency program, they are well trained to focus on chronic and preventative care management. This legislation's intent is not to turn APRNs into physicians nor is it intended to give them autonomy to make complex diagnostic decisions. This bill will allow them to have greater freedom to practice in clinical settings within their existing scope of practice. I think it is important for APRNs and physicians to have productive collaborative relationships, but not supervisory ones. Research indicates that written practice agreements often become a formality that does not foster meaningful interaction between APRNs and physicians.

Nearly 90 percent of APRNs work in primary care. With the influx of new patients into the health care system, there is a great need for expanded primary care services and APRNs play a vital and necessary role in meeting this need. Laws that restrict how and where APRNs practice or how they may be employed only restricts health care services in our state.

NATURE AND SOURCES OF SUPPORT:

Mary Jane Williams, Connecticut Nurses' Association: I speak in strong support of the bill. In 1999 when the provision for the scope of practice review became law it was mutually agreed on that in five years we would revisit the language and move forward with “Independent Practice”.

Our goal should be to develop statewide infrastructure to address ongoing ever-changing health care needs of a growing number of patients who will need quality care in a timely manner. The bill will help to address the issues with vulnerable populations in many of our communities who have not had or who have had minimal access to health care. These individuals will now have health care insurance coverage and require providers.

We have excellent community models of care that are led by APRNs. The community facilities provide access to safe, high quality care with excellent outcomes. This proposed bill is essential to access.

The implementation of the “Affordable Health Care Act” and the implementation of “Access Health Connecticut” will increase the need for Primary Care Providers across the life span in all specialty areas of care. Passing this legislation will allow fully qualified APRNs to provide care across the life span in their area of specialization and is the right option at this time, during this current legislative session.

As the education, training, experience, and overall competence of health care practitioners have advanced over time, the distinctions between many health care professions in terms of their abilities to perform particular health care procedures have lessened.

This bill does not increase risk to public safety. The current literature provided to the Department of Public Health in support of the Scope of Practice review supports full scope of practice for APRNs. However, we are potentially decreasing access to care and interfering with a patients' ability to move along the continuum of care by not utilizing all health care practitioners. We need to focus on high quality, safe, cost effective care.

Julie Gombieski, APRN, MSN Family Psychiatric Nurse: Provided testimony to highlight her difficulties with obtaining a collaborating psychiatrist, at the time that she was starting her private practice. She receives numerous calls per week from both adults and parents of children who are looking for mental health treatment and encounter difficulty finding services.

There is a shortage of providers in the psychiatric field and removing a barrier to access to healthcare services is important for the people of this state. APRNs are very good at seeking out support and continuing education when our patient's health status does not improve and we will continue to do so without this collaborative agreement.

I urge the state to provide an alternative setting for ongoing collaboration for established providers in the community. A suggestion would be to have an interdisciplinary monthly meeting where community providers could come for guidance around complex cases. These could even be done via message boards or online support systems. This would help to increase community ties between all disciplines which may further help the populations we serve.

JoAnn Eaccarino: I am in strong support of the bill. I have been a board certified Family Nurse Practitioner for over 30 years and have worked in private practices and other health care facilities, most recently in School Based Health Centers.

The act of collaboration is an ethical responsibility of all professional persons. Nurse Practitioner will not cease to collaborate if this legal requirement is removed. Collaboration and referral to physicians or to other more experienced healthcare professionals with specialty practices, has never been based on any legal requirement, but rather in the best interest of the patients.

Vanessa Pomarico, APRN, President, Connecticut Advanced Pratice Registered Nurse Society: I am a practicing APRN for the past 16 years in a private, internal medicine practice. Additionally, I serve as the Interim Director of the Family Nurse Practitioner Track at Southern Connecticut State University educating tomorrow's practitioners.

I want to emphasize that it is inherent in our profession, both ethically as well as medically, to consult and collaborate with other providers when the need arises in the care of any patient. Removal of the collaborative agreement will in no way jeopardize the safety of our patients.

APRNs have a long history of well-documented patient safety and patient satisfaction. We make no fewer or no more referrals than our MD colleagues do to the emergency department or to a specialist. Removal of the collaborative agreement does not grant us authority we do not already have in our practices but will allow us to remain in practice upon the retirement, relocation or death of our MD colleagues thus providing care to the citizens of Connecticut.

Lynn Price, JD, MSN, MPH: I urge you to support the bill. Connecticut has a decreased number of physicians providing primary care and mental health services. Current law in Connecticut, derived 15 years ago, presents untenable and unnecessary barriers to APRNs wishing to provide these services, especially among the most vulnerable of our residents.

APRN practice has been well-researched and has been found to be safe and effective. The CT APRNs Request submitted a list of 27 studies on August 2013 substantiating this. Some of the highlights provided from the research noted that other states which allow full practice authority to APRNs experience the greatest growth of nurse practitioners providing primary care and APRNs practicing in “full scope” are less likely to relocate out of state. There are already 20 jurisdictions that have granted full scope of practice to APRNs, and in all of them, APRNs practice collaboratively with physicians and all other members of the health care team.

Karen Myrick, DNP, APRN - APRN Society's Government Relations Committee: As a Nurse Practitioner for 15 years, I have attempted to create a practice that would fulfill an identified state health care need, improve patient time to treatment and significantly improve access to care. The wait time has increased for a patient with Medicaid to be able to seen by a provider. Providers may have limitations that management imposes on scheduling patients with Medicaid, to seeing only two a day. With such a limited access to care, patients are at risk for complications that could be avoided.

Recognizing the issue with limited access and a health care need, I attempted to open a clinic for patients with Medicaid or from low-income families, who sustained a sports medicine injury. After contacting more than 20 orthopedic and sports medicine physicians, not one would sign a collaborative agreement for this endeavor. Please support this bill to eliminate an impractical barrier that fulfills no public health policy purpose, but does provide a barrier to accessing appropriate health care.

Connecticut Hospital Association: Supports the bill as written. SB 36 seeks to eliminate the requirement of a collaborative agreement of Advanced Practice Registered Nurses (APRN) with three or more years of licensure. APRNs with less than three years of licensure will still be required to maintain a collaborative agreement.

The bill facilitates flexibility in the access to and provision of care across the continuum. However, unless corresponding changes are made to the way in which the Medicaid program reimburses providers for the types of primary care services delivered by APRNs, the effect of the bill will be nullified. Currently DSS refuses to reimburse hospital-based services provided by APRNs, including services provided by clinics, affiliated practices, and with the hospital itself, unless a collaborative agreement is in place and a physician specifically approves the services. Those limitations mean that without altering DSS policy, SB 36 will not change how APRNs are able to function in hospital-based settings.

Dr. Regina Cusson, Dean of the School of Nursing, University of Connecticut (UCONN): UCONN, Connecticut's largest state-affiliated university, has trained and educated nurse practitioners – APRNs – for more than 30 years.

The national trend of states moving toward full practice authority already includes 17 states, plus the District of Columbia, fully one third of the nation. Four of those states, Maine, New Hampshire, Vermont, and Rhode Island, are here in New England. At least 12 other states have bills in their legislatures to follow suit. As more states move to full practice authority of APRNs, restrictive states will fall behind. Some states are already proposing incentives to draw APRNs away from states like ours, with more restrictive laws.

With 7 university level in-state nurse practitioners Connecticut invests heavily in educating APRNs, How unfortunate will it be when we lose this precious commodity to neighboring states with more favorable practice environment?

Quality outcome research studies on APRN practice are plentiful, all concluding that health care delivered by APRNs is safe, high quality, and cost-effective. Empowering APRNs to practice to the full extent of their training and education will support our health care infrastructure in Connecticut and increase health care access for patients. To those who would attempt to argue that passing this law would end inter-professional collaboration, it is far from the truth. As an educator, inter-professional collaboration with all licensed health care providers is the hallmark and cornerstone of APRN training and education.

Lynn Rapsilber, Chair, Connecticut Coalition of Advanced Practice Nurses: Last year there were 78 legislators who sponsored similar language to the bill before us.

The APRN scope of practice review process conducted last August consisted of 40 individuals and groups both in support and in opposition to discuss the merits of the request. Among the items discussed were quality, safety, education, cost and access.

First, over 40 years of studies demonstrating APRN outcomes are as good as or better than physicians. There was no data to support any harm to the public by removing the requirement for agreement. As for education, yes APRNs are trained differently from physicians. APRNs are population focused, competency based, with a holistic approach to education and training. We have national standards of certification and continuing education. Data shows we can reduce costs in disease management and as a part of a nurse led Patient Centered Medical Home. The DPH Report specifically refers to documentation of cost savings including lower drug costs, lower per-patient costs, lower visit costs, and lower costs associated with lower rates of emergency department referrals. The last area discussed was access. Connecticut has provider shortage areas for physicians for primary care and behavioral health in all outcomes. APRN practices are at risk to close, unable to grow and not able to open due to this outdated mandated agreement.

NOTE: There are an additional 55 statements-of-support available online.

NATURE AND SOURCES OF OPPOSITION:

Connecticut State Medical Society (CSMS: On behalf of the physicians and physicians in training, we are in strong opposition to Senate Bill 36. This legislation would grant advanced practice registered nurses (APRN) the authority to independently practice within a rather broad and vaguely-defined scope of what is now considered the licensed practice of medicine in Connecticut after completing three years of an equally broad and vague collaborative agreement.

Current statute requires a critical bond between the APRN and collaborating physician to ensure that the patient receives the right care for the right reasons at the right time. By removing the requirement for collaboration with a physician, the APRN alone would make all treatment decisions, whether the APRN is working with a patient with a single episode of care or with a patient who has multiple co-morbidities involving complex and often varied treatment modalities. If passed, the bill would allow APRNs to pen their own practices to evaluate, diagnose, and provide treatment for potentially complex and life-threatening diseases. It would further allow APRNs to independently prescribe, administer, and dispense medications to patients, including controlled substances that require the development of patient treatment plans. All of this would take place without the benefit of oversight from a licensed physician with years of clinical training and practice.

APRNs are valuable care extension resources, but they are not a substitute for a trained and licensed physician. Throughout the discussion and debate on this issue we have clearly demonstrated a difference in education and training between physician and APRNs. The differences cannot be overlooked. The average physician completes 3,200 hours of clinical training in medical school and 9,000 hours during residency. This extensive education and training provides physician with the skills and experience to diagnose and treat complex medical problems. Depending on specialty, physicians are required to complete additional hours of accredited hours of accredited Continuing Medical Education (CME) to receive and maintain board certification. This is significantly greater than CME requirements of 50 years over a two-year period contained in state statutes.

The average APRN completes 500 hours of clinical training prior to practice. APRN education and training focuses on competencies such as health promotion, disease management and care coordination. These skills are important component of positive patient health outcomes, but not equivalent to those of a physician and should be considered when the determination is made whether or not to provide complete independence without the need for any involvement with a physician.

Every patient deserves the confident of knowing that a fully-trained physician is involved in the course of his or her medical care. Three years of a very loose defined collaboration prior to complete independence is unacceptable. Physicians in collaboration are not direct supervisors. Collaboration is not a substitute for the intensive, highly supervised minimum three years of residency and additional years of specialty training prior to obtaining any ability to practice with autonomy.

Ken Yanagisawa, MD., Connecticut Society of Eye Physicians, Connecticut ENT Society, Connecticut Urology Society, The Connecticut Dermatology and Dermatologic Surgery Society: I am a board certified otolaryngologist and I am offering testimony in opposition to Senate Bill 36 on behalf of more than 1000 physicians in Ophthalmology, Ear Nose and Throat, Dermatology and Urology.

With the implementation of the Affordable Care Act, medicine is facing an access challenge. This legislation, however, does nothing to help with access. APRNs that are already in the state are seeing patients. Allowing them independent practice will not increase their number, nor expand the number of patients they can see in a day. Even if this attracts a flood or new APRNs to the state, it will be years before any significant increase in capacity could be realized.

Also you will lose the safety net currently provided by the collaboration agreements and this policy will lead to increased cost and delay in treatment. Additionally, patients requiring admission will require referral or coverage by an admitting physician, which will also create delays and safety risks.

In response to the issue raised regarding the cost of a collaborative agreement, while it may appear exorbitant however, the costs noted are without context. Many doctors provide not only oversight and review but the costs also covers material, supplies, rent education, liability coverage and the cost of their own increased liability from taking on the collaboration.

Waterbury Medical Association: We are in strong opposition to. We find the bill to be bad patient care.

The medial home concept is being recognized as a patient centered team approach to primary care. This is supported by the Affordable Care Act and integral to the development of Accountable Care Organizations. The team approach is more proactive in management of preventive health care and chronic disease management.

To provide APRNs full independence would undermine the patient centered team approach to care. A certain percentage would divorce themselves from the team model to continue the current model of fractionation of care and increased use of specialists.

Several studies have established that having a regular source of care and continuous care with the same physician over time leads to better health outcomes as well as lower costs, and medical homes are designed to provide this type of care. A recent survey by the Commonwealth Fund concluded that adults who have medical homes have enhanced access to care and receive better quality care. Given the benefits of the medical home, we question if APRNs would have any interest in joining a medical home if they were in independent practice.

We do not believe the educational and training requirements of an APRN are designed to allow for independent practice. Physicians' education is standardized such that the didactics, training and experience are consistent throughout the country. The education of APRN, on the other hand, may or may not include a bachelor's degree, a master's degree, or a doctorate, and the clinical training can be almost non-existent or even online. A physician cannot simply be replaced by another member of the team without creating different classes of care. While each member of the health care team has a role, they are not interchangeable.

Stacy Taylor, M.D., Connecticut Academy of Family Physicians: On behalf of the members of the Connecticut Academy of Family Physicians, and more importantly, on behalf of my patients, I stand in opposition to this bill.

For many years, we have presented our opposition to independent practice for APRNs, and this year is no different as we find it to be a fundamentally bad idea and poor patient care. It is the wrong approach and we do not support it. We will fight for patient safety.

The bill states that an APRN must have three years of collaboration with a practicing physician before becoming independent. Who will determine if the APRN is competent after that time? Is this the proper way to protect the public? Is three year's collaboration equivalent to a residency? Achieving independent practice through legislation rather than education is not the answer.

If after reading our testimony the decision is made to pass this legislation, it must include the following:

● “Truth in advertising”. Patients should know that they are being treated by an APRN and not a physician.

● APRN's must maintain medical malpractice limit similar to that of a physician and pay a comparable license fee.

● APRN's must go before the board of medicine and not the board of nursing.

● If APRNs were to practice without collaboration, they must be required to complete increased continuing medical education requirement equivalent to physicians.

Please note that these requirements are not an exchange for support. The Connecticut Academy of Family Physicians feels strongly that this bill is not good health policy.

NOTE: There are an additional 24 statements-in opposition available online.

Reported by: Virginia L. Monteiro

Date: March 24, 2014